Provider Demographics
NPI:1558695072
Name:REVELATION HOSPICE AND PALLIATIVE CARE, LLC
Entity Type:Organization
Organization Name:REVELATION HOSPICE AND PALLIATIVE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDRE'
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRKLAND
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:662-719-9209
Mailing Address - Street 1:89 DELTA AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-2749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:89 DELTA AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-2749
Practice Address - Country:US
Practice Address - Phone:662-719-9209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based